Shanay Walker's death in "just about the worse case of child cruelty it's possible to imagine" should be that lessons are learned, a coroner has said.
Nottinghamshire coroner Mairin Casey made the assertion about safeguarding the city and county's children in passing judgement on how the seven-year-old died.
As well as condemning Shanay's aunt, Kay-Ann Morris, she found failings from social services, staff at Shanay's school - Southglade primary - and healthcare staff, who missed opportunities to keep her safe.
She said the "course of events might have been different if at particular points organisations acted differently".
Shanay died in 2014 while in the care of Kay-Ann Morris. The youngster suffering a brain haemorrhage and her body was covered in more than 50 injuries.
Ms Casey said the view orchestrated by Morris that Shanay was a "difficult child rather than a child with difficulty" was a view adopted by many professionals, and it was highly unlikely that her injuries after January 2013 were due to self-harm.
She ordered that agencies including Ofsted, the General Teaching Council, Nottingham City Council and the ongoing Serious Case Review into Shanay's death be made aware of the "gravity" of Southglade headteacher Peter Smalley and learning mentor Laura Shreeves' "lack of commitment" to investigating safeguarding concerns about Shanay.
The inquest previously heard a safeguarding form raised by a teacher had been "duplicated" after it had gone missing in the days after Shanay's death.
In returning a narrative conclusion at Nottingham Coroner's Court, Ms Casey found that Shanay died on July 31, 2014, while in the care of her paternal aunt [Kay-Ann Morris] who had been approved as her special guardian in September 2012.
She added: "In the two years prior to her death she was the victim of sustained serious physical and emotional abuse.
"During the 48 hours before she died she was subjected to horrific violence resulting in multiple internal and external injuries, dying as a result of an injury to her brain cause by a blunt instrument, which on the balance of probabilities I find was an inflicted non-accidental injury."The court heard that in May 2011, Shanay went to live with foster carer Alison Robinson, who previously told the hearing Shanay was "on the whole a happy little girl". The coroner said Shanay showed "unruly behaviour" at school and at the foster home, associated with the transition.
Ms Casey said safeguarding referrals between January and July 2013 were not recorded in line with safeguarding procedures and were "wholly inadequate".She expressed her condolences to Shanay's mother, who was present.
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Having completed her degree, Lisa started work for Verisona Law in November 1999 in the Personal Injury department as a Trainee Litigation Clerk and since then has developed extensive skills in relation to personal injury litigation and case preparation.
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